NUR 401 SEPSIS CASE STUDYI: DATA COLLECTION
History of the present problem:
Betty Louise is an 82- year old female who has been feeling more fatigued for the last couple
days and has had a fever for the last 24 hours. She reports feeling full more often and has notices
a pink tinge in her urine...
betty louise is an 82 year old female who has been feeling more fatigued for the last couple days and has had a fever for the last 24 hours
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University of Alabama, Huntsville
SEPSIS CASE STUDY- Betty Louise
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SEPSIS
I: DATA COLLECTION
History of the present problem:
Betty Louise is an 82- year old female who has been feeling more fatigued for the last couple
days and has had a fever for the last 24 hours. She reports feeling full more often and has notices
a pink tinge in her urine when she urinates. She denies dysuria but admits to an increase in
urinary frequency for over a week. Her daughter brought Mrs. Betty Louise to the emergency
department (ED) when her mom did not know what day it was and could not tell her if she had
eaten or drank anything all day. Currently, Betty Louise is alert and has no history of dementia
or confusion.
Social History:
Betty Louise lives at home. She is widowed and has a son and daughter who are actively
involved with her on a daily basis. When her daughter, who is an RN, stopped by today, Betty
Louise had a dizzy spell and fell into the side of the closet door hitting her elbow hard causing a
skin tear and bleeding. She did not hit her head, only her elbow, but had to sit down because she
remained dizzy.
What data from the above histories is important and RELEVANT and have clinical significance
to you the RN?
RELEVANT Data from Present Problem: Clinical Significance:
Feeling more fatigued and having a Could indicated that the patient may
fever for the last 24hrs have some sort of infection such as an
Pink tinged urine UTI
Increase in urine frequency
Confusion with no past hx of dementia
or confusion
RELEVANT Data from Social History: Clinical Significance:
Dizzy spells are also an indicator in
Dizzy spell older adults that an infection is
Skin tear and bleeding present. The dizzy spells can put the
patient for risk of more injuries to
come. Also the skin tear can lead to
another source of infection.
Your text here
, Betty Louise has the following medical history and medication reconciliation:
Match the medication with the disease/diagnosis.
Past Medical History: Medication Reconciliation:
Type II Diabetes Mellitus 1. Allopurinol 100 mg bid
Hyperlipidemia 2. Colchicine 0.6 mg prn
Hypertension-Essential 3. ASA 81 mg daily
Gout 4. Pioglitazone (Actos) 15 mg daily
5. Simvastatin 20 mg qHS
6. Metoprolol 25 mg bid
7. Lisinopril 10 mg daily
8. Furosemide (Lasix) 20 mg daily
Lab/diagnostic results:
Basic Metabolic Panel Current Is it HIGHT/LOW/NL Previous value
(BMP) value
Sodium (135-145 mEq/L) 140 NL 138
Potassium (3.5-5.0 mEq/L) 3.8 NL 3.9
Glucose (70-110 mg/dL) 184 HIGH 128
Creatinine (0.6-1.2 mg/dL) 1.5 HIGH 1.1
Complete Blood Count
(CBC)
WBC (4.5-11.0 mm#) 13.2 HIGH 8.8
Hgb (12-16 g/dL) 14.4 NL 14.6
Platelets (150-450x 103) 246 NL 140
Neutrophils % (42-72) 93 HIGH 68
Misc. Chemistries
Lactate (0.5-2.2 mmol/L) 3.2 HIGH n/a
What labs are RELEVANT that must be recognized as clinically significant to you the RN?
RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable
Glucose Because the Worsening
patient is
diabetic therefore
its important to
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